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Application No:
NATIONAL INSTITUTE OF SPEECH & HEARING, THIRUVANANTHAPURAM
Karimanal PO, Akkulam, Thiruvananthapuram – 695583
Email - avtcourse@nish.ac.in. Website: www.nish.ac.in.
Application for Admission to Post Graduate Certificate Course in Auditory Verbal Therapy (PGCAVT)
2014-2015
NB: Kindly read the prospectus before filling up the application form.
Personal Details
Name of applicant (In Block Letters):
Expansion of Initials:
Date of Birth (DD/ MM/ YYYY):
Sex:
Mother tongue:
Name of Parent/ Guardian:
Occupation of Parent/ Guardian:
Are you an Indian citizen of Kerala Origin? :
If no, provide details:
Religion:
Caste:
Caste Category:
Physically handicapped: Yes/No
Contact Details
Telephone:
Mobile:
Email:
Permanent Address (In Block Letters):
District:
State:
Country:
Pin:
Mailing Address (In Block Letters):
District:
State:
Country:
Pin:
Academic Details
Details of Qualifying Examination: Please tick appropriate: MASLP / BASLP / B.Ed. (HI) / DTYHI
Institution where last studied with Year of study:
Name of the Board/ University:
Years of Experience:
Marks Obtained for Qualifying Exam
Qualifying Exam
Payment Details
Bank Txn Journal No:
Challan Amount:
Payment Date:
Marks Obtained
Maximum marks
% of Marks
Declaration
I,....................................................................... hereby certify that the details given in the application form are
correct. I do hereby declare that, if I am admitted, I shall abide by the rules and regulations of the Institute
and will not involve in any activity that may be detrimental to the orderly working and discipline of the
Institute.
Place :
Date :
Signature of the Applicant
I, …………………………………………………solemnly declare that all facts furnished in the application form for the
admission of my daughter/ son/ ward.......................................... are true to the best of my knowledge and
belief. I undertake that he/ she will abide by the rules and regulations of the Institute.
Place :
Date :
Signature of the Parent/Guardian
Name of the Parent/ Guardian ………………………………..
For Office Use
Admitted on …………………………………………
Admission No: ………………………………………….....
Course to which admitted ………………………………………………….
Certificates verified by (1)
(2)